RESEARCH ARTICLE Open Access Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey Vesile Senturk 1 , Melanie Abas 2 , Oguz Berksun 1 and Robert Stewart 2* Abstract Background: Social support is strongly implicated in the aetiology of perinatal mental disorder: particularly the quality of the marital and family environment. Family structures are important under-researched potential modifiers. Turkey offers particular advantages for research in this area because of long-standing coexistence of Western and Middle Eastern family structures. We aimed to investigate association s between the quality of key relationships and depression in women in their third trimester of pregnancy, and the extent to which these associations were modified by family structure. Method: Women attending antenatal clinics in their third trimester were recruited from urban and rural settings in Ankara. A nuclear family structure was defined as a wife and husband living alone or with their children in the same household, whereas a traditional/extended family structure was defined if another adult was living with the married couple in the same household. Depression was ascertained using the Edinburgh Postnatal Depression Scale (EPDS) and social support was assessed by the Close Person Questionnaire with respect to the husband, mother and mother-in- law. Social support was compared between participants with/without case-level depression on the EPDS in linear regression models adjusted for relevant covariates, then stratified by nuclear/traditional family structure. Results: Of 772 women approached, 751 (97.3%) participated and 730 (94.6%) had sufficient data for this analysis. Prevalence of case-level depression was 33.1% and this was associated with lower social support from all three family members but not with traditional/nuclear family structure. The association between depression and lower emotional support from the husband was significantly stronger in traditional compared to nuclear family environments. Conclusions: Lower quality of relationships between key family members was strongly associated with third trimester depression. Family structure modified the association but, contrary to expectations, spousal emotional support was a stronger correlate of antenatal depression in traditional rather than nuclear family setting s. Previous psychiatric history was not formally ascertained and the temporal relationship between mood state and social support needs to be clarified. Background Common mental disorders have a high prevalence in women, particularly at childbearing age [1]. It is increas- ingly recognised that many, if not the majority of cases of perinatal depression begin in the antenatal period and persist after childbirth [2]. Perinatal depression is a major health issue for many women from diverse cultures, although most often investigated in the postna- tal rather than antenatal period [3,4]. A meta-analysis of 59 studies reported a postnatal depression prevalence of 13% [5], although this varied widely between studies and was found to depend sub- stantially on the instrument and criteria used. British and Swedish studies have reported high maintenance rates (33-37%) and relatively low incidence rates (5-7%) of depression from the antenatal to postnatal periods [6,7]. Antenatal depression is therefore an important risk factor for postnatal depression and perinatal * Correspondence: r.stewart@iop.kcl.ac.uk 2 King’s College London (Institute of Psychiatry), London, UK Full list of author information is available at the end of the article Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 © 2011 Senturk et al; licensee BioMed Central Ltd. This is an Open Acce ss article distributed under the terms of the Creative Commons Attribution Lice nse (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. depression, whether antenatal or postnatal, represents an important public health problem [8,9]. However, research into antenatal depression has been very limite d. It has been estimated that the prevalence of antenatal depression may be as high as 20% [10, 11], although a system atic review by Bennett and colleagues estimated a prevalence of 12% in the third trimester [12]. Predispos- ing factors include a previous history of depression or mental disorder [10], but social support is also strongly implicated in the aetiology of perinatal mental disorder with the quality of the marital and family environm ent particularly pertinent [13-15]. The majority of research in this area has been carried out in Western settings with relatively homogeneous family structures and lim- ited generalisability to the rest of the world. Throughout the 20th century, Turkey has experienced substantial demographic, sociocultural and economic transformations. These changes have been said to be linked with adverse consequences such as poverty, unemployment, limited social services, and an imbalance in income distribution [16,17]. Taken together, these changes can be supposed to have an important impact on maternal he alth in the antenatal period that could be mediated through loss of traditional support networks. However, little is known about antenatal depression in Turkey, although postnatal depression has been found to be common [18], and Turkish research has generally confirmed risk factors suggested from Western popula- tions such as low income and socio-economic status, previous mental disorder, recent life e vents and per- ceived poor child health [19]. Level of social support has also been implicated in several studies: not only that from the husband [19,20] but also from the husband’s family and the wife’s parents [20]. Although t raditional family relationships in Turkey are believed to be strong, Inandi et al [21] observed that almost 40% of women complained of insufficient family support during preg- nancy. Golbası et al also found a moderate negative cor- relation between depression and perceived social support as well as positive correlations with maternal age, gravidity and number of living children [22]. A particularly important potential consequence of glo- bal population expansion and trans-national and rural- urbanmigrationhasbeenthedisruption of traditional family-based support structures common in Middle Eastern, as well as other societies. However, Turkey is almost unique as a nation in the length of time over which, and in the geographic proximity within which, both modern Western (’nuclear’) and traditional Middle Eastern (’extended’) family structures have co-existed. Comparisons between different family structures are important for women’s mental health because of the rapid ‘Westernisation’ of families occurring in many set- tings around the world and Turkish culture offers a particularly informative setting to investigate the longer term impact of these transitions. In the context of an ongoing prospective study of social support and perinatal depression carried out in Ankara, we analysed baseline data to investigate associa- tions between the quality of family relationships and depression in women in their third trimester of preg- nancy. Taking Turkish culture into account, the research was specifically focused on t he quality of three key relationships for a woman expecting children: i.e. with her spouse, with her mother and with her mother in- law. We further sought to investigate the extent to which these associations were modified by family struc- ture. The following a pr iori hypotheses were formulated forthebaselineanalysesofthisstudy:1)ante-natal depression will be associated independently with reduced reported quality of r elationship between the woman, her husband, her mother and her mother-in- law; 2) these associations will be evident for all three derived subscales of the Close Persons Questionnaire (emotional support, practical support and negative aspects of the relationship); 3) these associations will differ between traditional and nuclear family settings: in particular the association with lower quality of the spou- sal relationship will be stronger in nuclear family set- tings (anticipating that traditional structures, with the presence of other potentially supportive family members, may provide a buffering role for this association). Methods Setting The study was carried out in and around Ankara, the capital of Turkey, an appropriate setting because of the considerable heterogeneity of the population in terms of traditional Middle Eastern or ‘modern’ Western lifestyles and social environments. ‘Ankara’ here includes both central urban and semi-rural locations. In common with other Turkish cities, it has experienced rapid expansion and immigration. Many yo ung women living in urban districts have migrated as students or working adults and live a long distance away from their parents. On the other hand, in the surrounding more rural districts, womenwillbemorelikelytobecohabitingwiththeir family with traditional ties and expectations. Participants Samples were drawn from urban and rural antenatal clinics in and around Ankara. These clinics were purpo- sively selected to maximise population heterogeneity as it was not feasible to carry out a formal random sam- pling process. Attempts were made to interview all attenders for routine third trimester antenatal examina- tions within the study period from December 2007 to August 2008. Usual clinic attendance is at around 32 Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 2 of 10 weeks. Attendance for routine perinatal services are very high in Ankara: for example, attendance for measles and BCG vaccinations 93% and 92% respectively [23]. After approach, agreement and written informed consent, a brief interview was administered by a research team of trained interviewers (graduate-level research workers and trainee psychologists) at the time of clinic attendance. Participants did not receive a paym ent an d, as part of the consent process, were made aware that they were free to refuse the interview or any component of this without providing a reason and without any effect on their healthcare. Refusal reasons were mainly lack of time or no n-permission of the husband. Women with depressive symptoms were not formally re-evaluated clinically. However, women with moderate or severe depressive symptoms and wishing treatment were referred to their GP or to a psychiatrist. Measurements Depressive symptoms were ascertained using the Edin- burgh Postnatal De pression Scale (EPDS), the most widely used screening instrument for perinatal depres- sion in both international and Turkish research. It focuses on cognitive symptoms of depression and excludes somatic items which may generate false posi- tive cases in pregnancy and post partum [24]. It is a 10-item self-report measure with 0-3 scores for each item, giving a potential scale score range of 0-30, and has been validated in many settings including in Europe [25], Africa [26], and America [27]. The reliability and validity study of the scale in Turkish was established [28] using the SC ID as a gold standard, finding sensiti v- ity and specificity of 0.76 and 0.71 respectively. In another validation study in Turkey [29] sensitivity was found to be 0.84 and specificity 0.88. In both studies, the optimum cut-off point for caseness was calculated to be ≥13. The EPDS has also been validated as a screening tool for antenatal depression [30]. The ≥13 cut-off was applied in our study to define case level depressive symptoms (hereafter referred to as ‘depression’). Quality of individual relationships was measured using the Close Persons Questionnaire (CPQ) [31]. This is a widely applied instrument which focuses on three aspects of the quality of individual relationships - i) emotional support; ii) practical support; iii) negative aspects of the relationship (i.e. aspects of the relation- ship felt by the participant to make life more difficult for them) . In a depart ure from the standard application of this instrument (where participants are asked to choose their most salient relationships to be rated), the index relationships were imposed so that questions were asked specifically and solely about the spouse, mother, and mother-in-law. Data were coded as missing on these sections if this information could not be obtained (e.g. if the mother or mother-in-law was deceased). Othercovariatesinthisanalysiswereasfollows: 1) age, 2) number of living children, 3) education (self- reported, four groups), 4) family income (four groups), 5) self reported general physical health (five groups), 6) presence of self-reported life stressors/events (debt, hunger from lack of food, recent separation, problems with friends, recent illness/assault, violence to self, ill- ness in a relative, death of a close family member, death of another relative, problems with a job, problems with money, problems with the justice system, any robbery), 7) self-reported past history of emotional problems, 8) family structure. Family struct ure was defined as an effect modifier for analyses and was applied as a binary variable, categoris- ing into nuclear or trad itional/extended family structure. A nuclear family structure was defined as a wife and husband living alone or with their children in the same household, whereas a traditional/extended family struc- ture was defined if another adult was liv ing with the married couple in the same household. In Turkish society this would nearly always be the mother-in-law and/or father in-law of the woman since it is near- universal practice in traditional settings for women, following marriage, to live with their spouse’s family (i.e. it was not anticipated that there would be any families where the woman and her spouse were living with her own parents). Statistical analysis A target sample size of 750 women was calculated with the prospective study in mind, assuming a prevalence of 25% for case-level depression on the chosen scale at baseline, a maintenance rate of 30% through to the post- natal period, and a 0.5 standard deviation group differ- ence in mean score for a given quality of relationship measure between maintained and non-maintained groups at 80% power (alpha 0.05, 2-sided test). At the same level of power, this sample size was calculated as allowing the detectio n of a 0.3 standard deviation group difference between participants with and without case- level depression at baseline, assuming a more conserva- tive 13% prevalence. The sample was initially described with respect to the covariates and associations between these and depression (EPDS caseness) was expressed through odds ratios and assessed using chi-squared tests. Although caseness on the EPDS was the primary ‘out- come’ , in order to make use of the continuously dis- tributed data on social support, the CPQ subscales were treated as dependent variables (i.e. testing the dif- ferences in social support scale means between Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 3 of 10 participants with or without case-level depression) using t-tests initially to investigate significance. We then opted to use linear regression models to adjust for covariates. The sample size was felt to be sufficient to justify this approach of linear modelling, despite non- normal CPQ subscale distributions. Separate regression models were used for each CPQ subscale as a dependent variable with EPDS caseness entered and assessed as a binary independent variable on each iteration. Covari- ates were entered sequentially in the following groups: i) Model 1 adjusting for age only; ii) Model 2 adjusting for age, parity, education and family income; iii) Model 3 adjusting for age, parity, education, family income, physical health and number or life stressors/events; iv) Model 4 adjusting for age, parity, education, family income, physical health, number of life stressors/even ts and self-reported previous emotional problems. As a secondary analysis, the fully adjusted model (Mo del 4) was re-run with EPDS score as a continuously distribu- ted independent variable to check for linearity of asso- ciations. Stratified analyses were used to investigate effect modificatio n by family structure with interaction terms re-tested in linear regression models. In a more exploratory analysis, effect modification by the prese nce or not of previous childbirth w as investigated in a simi- lar way through separate models. Results Of the 772 women approached in their third trimester, 751 (97.3%) participated in the study. The reasons for non-participation were: refusal (n = 18) and insufficient literacy (n = 3). Thirty-one incomplete questionna ires had to be further excluded. Therefore, 730 (9 4.6%) were included with sufficient data for this analysis. The num- bers of participants with complete data on the emotional support, practical support and negative aspects measures were 665, 670 655 for the mother respectively and 635, 649 and 633 for the mother in-law respectively. All 730 had spousal data. Sample characteristics Distributions of covariates are summarised in the first column of Table 1. The mean age was 25.9 years (SD 5.3, range 18-44), an d the mean duration of education was 8.4 ye ars (SD 4 .5, range 1-34). Almost all partici- pants were living with their husband and close to a third (29%) were living in traditional family environ- ments. Over half (53%) had no children. The majority (80%) described their physical health as at least good, although emotional problems in the past were reported by around half (49%) of the sample and the prevalence of reported violence in the last 12 months was 6%. Around a third (33%) had depression according to the EPDS≥13 cut-off point. Associations between covariates and depression Unadjusted associations with depression are summarized in the remainder of Table 1. Depression was associated with higher numbers of previous children, worse general health, previous/current life events/stressors, and self- reported past history of emotional problems. There were no significant associati ons with age or education level. Depression was associated with lower family income, although only at borderline significance levels. Associations between depression and social support Differences in social support measures between partici- pants with or without depression are summarised i n Table 2. In summary, women with case level depres sion reported worse social support (lower emotional and practical support, higher negative aspects of r elation- ships) on all nine variables, apart from a lack of associa- tion with practical support from the mother. Adjusted associations between depression and social support m easures are displayed in Table 3. Adjustment for ag e had little impact on these, but there were mod- est reductions in the strengths of association following adjustment for number o f children, duration of educa- tion, and family income. Further r eduction was observed, particularly for the emotional support mea- sures after adjustment for physical health and number of life events/stressors, with little or no subsequ ent change following adjustment for self-reported past emo- tional problems. In the final, fully adjusted model, depression remained significantly associated with all three measures of social support from the husband, with lower practical and emotional support from the mother- in-law and with higher negative aspects of the relation- ship with the mother. A secondary analysis, entering EPDS score as a continuous independent variable (rather than a binary case vs. non-case variable), gave esse ntially similar findings with significant negative cor- relations of EPDS score with emotional and practical support from the spouse and mother-in-law and emo- tional support from the mother. Significant positive associations were found with negative aspects of the relationship with all three relatives (data available on request). Effect modification by family structure and previous childbirth Stratified analyses investigating effect modification are summarised in Table 4. Overall, the associations between depression and social support were not modi- fied substantially by family structure - in particular, there was no evidence for differen ces in the role of rela- tionship with the mother-in-law, which appeared equally strong in both environments. Contrary to the apriori hypothesis, associations with spousal relationship were Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 4 of 10 Table 1 Unadjusted associations between participant characteristics and prevalence of case-level depressive symptoms n Depression prevalence (%) ORs (CIs) c 2 (df), p-value Age 0.03 (1) p = 0.86 18-22 199 33.7 Reference 23-25 166 37.3 1.18 (0.76-1.81) 26-44 172 25.0 0.66 (0.42-1.03) 30-44 168 36.9 1.15 (0.75-1.77) Number of children 4.90 (1) p = 0.03 0 379 31.4 Reference 1 230 29.6 0.92 (0.64 - 1.31) ≥2 111 45.9 1.86 (1.21 - 2.86) Education level (year) 0.14 (1) p = 0.71 ≤5 229 32.3 Reference 6-8 143 32.9 1.03 (0.66 - 1.60) 9-11 240 34.2 1.09 (0.74 - 1.60) 11≥ 82 26.8 0.77 (0.44 - 1.35) Family income (TRY) 3.09 (1) p = 0.08 ≤630 169 36.7 Reference 631-900 172 36.0 0.97 (0.63 - 1.51) 901-1400 243 29.6 0.73 (0.48 - 1.10) 1401- 23000 93 29.0 0.71 (0.41 - 1.22) Physical health 9.33 (1) p < 0.001 Very good 129 30.2 Reference Good 446 29.6 0.97 (0.63 - 1.49) Average/bad/very bad 142 47.2 2.06 (1.25 - 3.40) Life events/stressors 43.7 (1) p < 0.001 0 406 23.6 Reference 1 174 31.0 1.46 (0.96 - 2.20) 2 90 43.0 2.45 (1.49 - 4.03) 3 69 55.0 3.96 (2.02 - 7.77) 4+ 27 70.4 7.70 (3.24 - 18.29) Past emotional problems 71.0 (1) p < 0.001 No 358 18.7 Reference Yes 340 48.8 4.14 (2.95 - 5.82) Family structure 0.08 (1) p = 0.77 Nuclear 471 32.7 Reference Traditional 249 33.7 1.05 (0.76-1.45) Table 2 Unadjusted associations between social support and depressive symptoms Nature of support Mean (SD) social support Difference (cases vs. non-cases) Non-cases n = 482 Cases n = 238 Beta coefficient (95% CI) p-value From husband Emotional 19.4 (4.6) 15.4 (6.1) -4.0 (-4.8, -3.2) < 0.001 Practical 7.0 (2.0) 5.9 (2.4) -1.1 (-1.4, -0.7) < 0.001 Negative aspects 6.2 (2.2) 7.8 (2.2) 1.6 (1.2, 1.9) < 0.001 From mother Emotional 17.1 (5.3) 15.3 (6.0) -1.8 (-2.7, -0.9) < 0.001 Practical 5.5 (2.8) 5.4 (3.1) -0.1 (-0.6, 0.4) 0.62 Negative aspects 5.3 (2.1) 6.0 (2.2) 0.7 (0.3, 1.0) < 0.001 From mother in law Emotional 11.3 (7.0) 6.9 (6.2) -4.4 (-5.5, -3.2) < 0.001 Practical 4.3 (3.1) 3.0 (3.0) -1.3 (-1.8, -0.8) < 0.001 Negative aspects 5.5 (2.4) 6.3 (2.9) 0.8 (0.3, 1.2) < 0.001 Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 5 of 10 stronger in traditional compared to nuclear family set- tings: significantly so f or lower emotional support as a correlate and of borderline significance for practical sup- port. Also of borderline statistical significance was an apparent difference in maternal relationship as a corre- late, depression being associated with lower practical support from the mother in a nuclear family setti ng but with higher practical support from the mother in a tra- ditional family se tting. Considering previous childbirt h as an effect modifier, the association between depression and lower emotional support from the husb and was stronger for women with no previous children; however, associations did not differ between g roups with respect to other components of the spousal relationship or with quality of the other two relationships. Discussion Inasampleof730womenintheirthirdtrimesterof pregnancy recruited in and around Ankara, we found that lower quality ratings for three key relationships - with the spouse, mother and mother-in-law - were asso- ciated with case level depression as defined from the Edinburgh Postnatal Depression Scale (EPDS). The asso- ciation between lower quality spouse relationship and depression was stronger in women living in a traditional rather than nuclear family arrangement. Table 3 Adjusted associations between social support and depressive symptoms Nature of support Association with case-level depressive symptoms (B-value, 95% CI) Unadjusted Model 1 Model 2 Model 3 Model 4 From husband Emotional -4.0 (-4.8, -3.2)* -4.0 (-4.8, -3.2)* -3.7 (-4.6, -2.9)* -2.9 (-3.8, -2.0)* -2.6 (-3.6, -1.7)* Practical -1.1 (-1.4, -0.7)* -1.1 (-1.4, -0.7)* -0.9 (-1.3, -0.6)* -0.7 (-1.1, -0.3)* -0.6 (-1.0, -0.2)* Negative aspects 1.6 (1.2, 1.91)* 1.5 (1.2, 1.9)* 1.5 (1.1, 1.9)* 1.3 (0.9, 1.7)* 1.3 (0.8, 1.7)* From mother Emotional -1.8 (-2.7, -0.9)* -1.8 (-2.7, -0.9)* -1.6 (-2.6, -0.7)* -1.0 (-2.0, 0.1) -1.2 (-2.3, 0.2) Practical -0.1 (-0.4, 0.6) -0.1 (-0.6, 0.4) 0.2 (-0.3, 0.6) 0.3 (-0.3, 0.8) 0.3 (-0.3, 0.8) Negative aspects 0.7 (0.3, 1.0)* 0.6 (0.3, 1.0)* 0.7 (0.3, 1.1)* 0.7 (0.3, 1.1)* 0.7 (0.2, 1.1)* From mother in law Emotional -4.4 (-5.5, -3.3)* -4.4 (-5.5, -3.3)* -4.3 (-5.5, -3.2)* -3.8 (-5.1, -2.6)* -2.6 (-4.6, -1.9)* Practical -1.3 (-1.8, -0.8)* -1.3 (-1.8, -0.8)* -1.2 (-1.7, -0.7)* -1.0 (-1.5, -0.5)* -0.8 (-1.4, -0.3)* Negative aspects 0.8 (0.3, 1.2)* 0.8 (0.3, 1.2)* 0.8 (0.4, 1.3)* 0.7 (0.2, 1.2)* 0.4 (-0.1, 1.0) *p < 0.05. Model 1 Adjusted for age. Model 2 Adjusted for 1 and number of children, duration of education, family income. Model 3 Adjusted for 2 and physical health, number of life stressors/events. Model 4 Adjusted for 3 and previous emotional problems. Table 4 Stratified analysis of associations between social support and depressive symptoms. B-coefficients with 95% confidence intervals are displayed Total Family structure Current family size Nuclear n = 471 Traditional n = 249 p-value* 0 child n = 379 1+ children n = 341 p-value* From husband Emotional -4.0 (-4.8, -3.2) -3.2 (-4.2, -2.2) -5.4 (-6.8, -4.1) < 0.01 -4.7 (-5.8, -3.6) -3.2 (-4.3, -2.0) 0.05 Practical -1.1 (-1.4, -0.7) -0.8 (-1.3, -0.4) -1.4 (-1.2, -0.9) 0.10 -1.1 (-1.5, -0.6) -1.0 (-1.5, -0.5) 0.44 Negative aspects 1.6 (1.2, 1.9) 1.6 (1.2, 1.1) 1.4 (0.9, 2.0) 0.58 1.5 (1.0, 2.0) 1.6 (1.1, 2.2) 0.28 From mother Emotional -1.8 (-2.7, -0.9) -1.5 (-2.6, -0.4) -2.3 (-3.9, -0.8) 0.37 -1.6 (-2.7, -0.5) -1.9 (-3.3, -0.5) 0.24 Practical -0.1 (-0.4, 0.6) -0.4 (-1.0, 0.2) 0.5 (-0.3, 1.2) 0.07 0.6 (0.0, 1.1) -0.7 (-1.4, 0.0) 0.10 Negative aspects 0.7 (0.3, 1.0) 0.7 (0.2, 1.1) 0.7 (0.1, 1.3) 0.95 0.6 (0.1, 1.1) 0.8 (0.2, 1.3) 0.18 From mother in law Emotional -4.4 (-5.5, - 3.2) -4.0 (-5.4, -2.6) -5.1 (-6.9, -3.3) 0.34 -4.6 (-6.1, -3.0) -4.0 (-5.5, -2.4) 0.42 Practical -1.3 (-1.8, -0.8) -1.3 (-1.9, -0.7) -1.4 (-2.2, -0.7) 0.74 -1.1 (-1.8, -0.5) -1.4 (-2.1, -0.7) 0.49 Negative aspects 0.8 (0.3, 1.19) 0.8 (0.2, 1.3) 0.7 (0.1, 1.4) 0.90 0.8 (0.3, 1.4) 0.7 (0.1, 1.4) 0.56 *Testing heterogeneity of regression coefficients between strata. Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 6 of 10 As discussed earlier, antenatal depression persists into the postnatal period in a large proportion of cases and many cases of postnatal depression begin in the antena- tal period [6,7]. Antenatal depression therefore repre- sents an important clinical and public health issue [8,9] because of the potential for early intervention. Although there have been reports of puerperal psychosis preceded by antenatal depression [32], postnatal depression as the much more common outcome is likely to be the most important focus for prevention. However, as discussed, there has been relatively little research into antenatal depression and its correlates. Findings from this study show similarities and dissimilarities compared to other studies in terms of potential risk factors for antenatal depression. Social support, life events, violence were associat ed with depression in one study whereas age, education level and income were not [33,34]. In another study, risk factors for depression during pregnancy included younger age and lower education [35,36]. Increased parity and lack of support, particularly poor support from the partner/husband have also been asso- ciated with depression in both developed and developing countries [34,37]. In particular, physical abuse by i nti- mate partners before or during pregnancy has been found to be a part icularly important potential risk factor for antenatal depression [35,36]. In this analysis, the focus was on social support and relationship quality spe- cifically; however, unadjusted analyses revealed associa- tions with increased parity, worse self-rated physical health, higher number of lifeeventsandself-reported past emotional problems. On the other hand, depression was not significantly associated with age, education, income or traditional/nuclear family structure. These findings suggest at least some level of heterogeneity between settings in correlates of antenatal depression, although methodological differences with respect to sampling and measurement cannot be excluded as an underlying reason for this. Although it was not the primary objective of this ana- lysis to investigate differences in the prevalence of antenatal depression between traditional and nuclear family settings, the observed lack of difference is poten- tially interesting. In the Turkish context, the two family models have co-existed for many decades and there is relatively little stigma attached to women living in either family model. In particular, we do not feel that women in nuclear settings have had to ‘extract’ themselves from traditional settings and thus we do not feel that the woman’s personality or the a ttitudes of her family are likely to be a major factor. Largely, the family model i n which a woman is living depends on issues such as the availability of work and accommodation. Further analy- sis would be required to clarify whether there was any negative confounding, obscuring a true difference in depression prevalence between settings. However, this wasbeyondthescopeofthispaperwhichsoughtto focus on associations between depression and social relationships and the role of family structure as an effect modifier rather than as an exposure itself. To our knowledge, ours is the first study which has assessed the association between antenatal depression and support from the mother and mother in-law, although this has been investigated previously for post- natal depression in Turkey [36]. In our sample we found strong associations between depression and nearly all measures of social support from the three relatives in question. Those with the husband an d mother-in-law were particularly stron g, which is consistent with the importance of these figures in women’s lives in this cul- ture. The only exception was that negative aspects of the relationship with the mother were more strongly associated with dep ression than those with the mother- in-law. However, this might possibly reflect a long- standing poor parental relationship prior to marriage but with lasting effects on mental health. As mentioned earlier, Turkey in general (and Ankara in particular) offers important advantages for research into the role of different family structures because of the longstanding co-existence of ‘ Western’ and tradi- tional ‘Middle Eastern’ cultures. The relationship between women and their mother and mother in-law is still important in Turkish culture, whether the woman is living in a nuclear or extended family setting. In Turkish traditional settings, a woman will typically move to live with her husband and his family in the same house when she gets married. In this setting, the expected role of a woman’s own mother is to support this marriage by helping her daughter on practical issues (e.g. taking care of children) and emotional issues. The study was specifi- cally set up to investigate these issues, funded through theWellcomeTrust’ s ‘Health Consequences of Popula- tion Change’ programme which sought to support research into the potential health impacts of rapidly changing societies. We investigated whether an extended family setting might modify potential effects of spousal and other key relationships on depression risk, specifi- cally hypothesising that the presence of other family members would reduce the impact of a poor quality spousal relationship. Contrary to our hypothesis, effect modificationintheoppositedirection was found with stronger associations between spousal support and depression in traditi onal families, particularly with respect to lower emotional support as an exposure. This requires confirmation in other samples. However, it may reflect a higher visibility of marital difficulties in extended families and hence a stronger impact on depression. It might also reflect families taking the side of the husband and feelings of isolation of the woman Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 7 of 10 in question. The stronger association in women without previous children might reflect a buffering effect of other children on the impact of marital s train or possi- bly higher feelings of empowerment in this group of women and/or the presence of children allowing greater access to friends and extra-familial support networks. Also of interest was the observation that the associa- tion with social support from the mother-in-law was equally strong in nuclear and traditional families, emphasising the importance of this relationship in Turk- ish culture, and with implications for future clinical and public health interventions. The association with sup- port from the mother was, as mentioned, weaker in most respects, and the observation of possibly opposite associations with daughters’ depression between tradi- tional and nuclear families might reflect differing roles of the mother in t he two situations. Higher practical support from the mother in the co ntext of an extended family structure (i.e. for women liv ing with their hus- band’s family) might represent a more severe breakdown of relationships in the household where women are residing. Support from family members has been found to be an important buffer against depression in women from other low and middle inco me settings [37]. Some research into perinatal mental disorder in Islamic nation settings has suggested both high prevalence of disorder and a potentially harmful role of disruptions to tradi- tional family structures [38]. Although a high prevalence of antenatal depression was found in our sample, consis- tent with this, there was little evidence that traditional family structures conferred additional protection, either directly or through buffering effects of individual rela- tionships. However, it should be borne in mind that these nuclear and traditional structures have co-existed in Turkey for a long time, potentially allowing individual and societal adjustment. Results cannot necessarily be generalised to nations or cultu res undergoing more rapid changes and further research is required in these settings. Strengths of this study include the particular features of the setting, as mentioned, the large and heteroge- neous sample, the standardised assessment instruments which have been well-validated in a variety of interna- tional settings, and a comprehensive range of covariates. Random sampling of antenatal clinics was not feasible in this setting because of difficulties in enumeration of these. An approach was taken instead to maximise the heterogeneity of populations served which we belie ve constituted the next best approach to sampling. Response rates were relatively high and we believe that the findings should generalise to the source populations. The Edinburgh Postnatal Depression Scale used in this study is, as stated, widely used in international research. However, it should be borne in mind that it is a screen- ing instrument, measuring number of depressive symp- toms and does not seek to define specific depression syndromes. Furthermore, it is possible that other syn- dromes such as anxiety may influence caseness on this instrument. ‘Depression’ is therefore used as a shorthand term to describe case level symptomatology on this instrument, but it should be borne in mind that this is not synonymous with a clinical diagnosis and that clini- cal. Other principal limitations arise from the cross- sectional nature of this analysis. In particular, associa- tions between lower social support and depression might reflect response bias in people with depression, or might reflect an effect of depression (the current episode and/or earlier episodes) on interpersonal relationships and actual levels of support, as well as the causal rela- tionship of inte rest betw een low social support and risk of depression. In thi s respect, a key limitation is that there was little information on history of previous depressive episodes, whether known or unknown to clinical services, and further follow-up of this sample is currently underway which will seek to address these issues. Conf ounding factors were addressed as compre- hensively as possible; however, residual confounding cannot be excluded. For example, personality was not measured although this is a factor that could have potentially influenced interpersonal relationships as well as risk of depressive episodes. Conclusions In a large community sample of Turkish women in their third trimester of pregnancy, strong associations were found between depression and lower measures of social support from the husband, mother and mother-in-law. Taki ng advantage of the wide range of f amily structures of participants in this setting, we investigated the modi- fying r ole these might have on the associ ations of inter- est. In summary, and contrary to our hypothesis, we found that lower quality of the spousal rel ationship had stronger rather than weaker associations with depression in traditional, extended family settings. Lower quality of emotional support from the husband was also more strongly associated with depression in women with no previous children. There has been considerable concern around changes in family structures over the last 100 years and their impact on mental health. Turkey, in common with other Middle Eastern countries has been pa rticularly affected, although changes have been occurring over a relatively longer period. T o our k nowle dge, ours is the first study to investigate the role of the family structure and social support within the family as aetiological fac- tors for antenatal depression and we believe that our Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 8 of 10 findings provide a template for further research both in Turkey and elsewhere. List of abbreviations (EPDS): Edinburgh Postnatal Depression Scale; (CPQ): Close Persons Questionnaire; (SD): Standard deviation; (95% CI): 95% confidence intervals. Acknowledgements The authors express their thanks to staff at the participating antenatal clinics for their support with the study, to the women who agreed to interviews, and to the research assistants who carried out the interviews. The study was funded by a Wellcome Trust Masters Training Fellowship and a further Wellcome Trust PhD Prize Studentship awarded to the first author. RS is funded by the NIHR Specialist Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s College London. None of the stated funding bodies had any input into the post-funding study design, data collection or analysis, or into the decision to submit this manuscript for publication. Author details 1 Department of Psychiatry, Ankara University Medical School, Ankara, Turkey. 2 King’s College London (Institute of Psychiatry), London, UK. Authors’ contributions Funding for the study, as designed, was obtained by VS, RS and OB. The study from which data are reported was carried out by VS under the supervision of RS, MA and OB. Data were analysed by VS who prepared this report to which RS, MA and OB contributed critical comment. 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Psychol Med 2003, 33:1161-67. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-244X/11/48/prepub doi:10.1186/1471-244X-11-48 Cite this article as: Senturk et al.: Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey. BMC Psychiatry 2011 11:48. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Senturk et al. BMC Psychiatry 2011, 11:48 http://www.biomedcentral.com/1471-244X/11/48 Page 10 of 10 . this article as: Senturk et al.: Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey. BMC Psychiatry 2011 11:48. Submit your. history of emotional problems, 8) family structure. Family struct ure was defined as an effect modifier for analyses and was applied as a binary variable, categoris- ing into nuclear or trad itional /extended. RESEARCH ARTICLE Open Access Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey Vesile Senturk 1 , Melanie Abas 2 , Oguz